After Mitch McConnell, the Senate Majority Leader, released a draft of the Senate health-care bill, on Thursday morning, the media finally began focussing on the essence of what Republicans are proposing: an enormous redistribution of wealth into the pockets of the already-wealthy. The bill would modify the health-insurance subsidies introduced under the Affordable Care Act and dramatically cut Medicaid, all to deliver a big tax cut to the nation’s richest households. But there’s another aspect of the legislation that has received less attention, and that’s the way it staggers its various provisions, and claims billions of dollars in savings that are far from guaranteed.
If McConnell’s proposal were signed into law, the tax cuts for families earning more than a quarter of a million dollars a year would take effect immediately—in fact, they would be backdated to the start of the 2017 tax year. But many of the other big provisions in the bill would only take effect down the road. The changes to the private-insurance market would be felt later this year and early next year, as people purchased individual plans for 2018. The big cuts to Medicaid wouldn’t happen until 2021, and some of them would be delayed for another four years beyond that.
Thanks in large part to the Affordable Care Act, passed under President Obama, Medicaid and its sibling, the Children’s Health Insurance Program, now provide health care to about seventy-five million Americans, including about thirty-six million children. The Senate bill, in addition to rolling back the A.C.A.’s expansion of Medicaid, starting in 2021, would also change the way that Medicaid is financed, converting it into a block-grant program—meaning that the federal government would cap the amount of money it gives to states, which administer the program. From 2025 onward, a strict new formula would limit future expenditure growth.
Part of the rationale for this timetable is obvious. If the proposed Medicaid changes are fully enacted, they will knock many millions of needy people off the federal program’s rolls. By delaying the implementation, McConnell and his colleagues are hoping to win over moderate Republican senators, such as Susan Collins, of Maine, and Rob Portman, of Ohio, whose votes they need to pass the bill. Why don’t Republicans forgo the cuts to Medicaid completely? Partly because they are ideologically opposed to expanding the social safety net, which is what the Medicaid expansion did. But they also need the Medicaid cost savings to get the tax cuts they want—not just in this bill but also in the broader tax-reform measure they hope to pass.
http://www.newyorker.com/news/john-...-at-the-center-of-the-gops-health-care-reform
